Has the day of reckoning for the U.S. dialysis entitlement finally arrived?

An article in today’s New York Times by Gina Kolata says it has, and to me it seems like it’s about time. Kolata’s report notes that a committee of nephrologists assembled by the Renal Physicians Association recently drew up guidelines on which patients are appropriate dialysis candidates from a medical perspective and which are not, a test that until now has often not been applied to patients with end-stage renal disease. The new guidelines call for physicians and patients to discuss the patient’s condition and arrive at a mutually agreed on decision as to whether dialysis is the right course of action.

One of their criteria: Physicians treating a patient should ask themselves whether, even with dialysis, the patient likely has a year to live.

dialysis machine/image courtesy Flickr user jimforest

As the Times article summarizes, in 1972 Congress made free dialysis a right for just about any American with failing kidneys. The program now includes 400,000 patients with an annual bill of $40-$50 billion, and with those older than 75 the fastest growing segment of the dialysis patient load. The 1972 law never anticipated a program of this scope, and at a time when Congress is haggling over whether the entire U.S. budget should get cut by $30 billion or $60 billion, a $45 billion program that has ballooned into a clinically questionable, medically-blind monster stands out. Aren’t there more pressing and cost-beneficial ways to spend America’s health care dollars than providing dialysis to all comers?

I have heard many cost-benefit analyses in my years as a medical journalist, and I never fail to be struck that the perennial benchmark is the quality-adjusted life years–the QALYs–that dialysis delivers. Since American society accepts the dialysis entitlement, any other treatment that delivers as much medical bang as dialysis for a buck is judged acceptable. Now, finally, American nephrologists have questioned the premise that underlies this benchmark.